We want to peel off the low-hanging fruit in May if we can ... we're facing real deadlines.'

' David Brailer, National Health IT Coordinator

Rick Steele

David Brailer is a doctor by trade, but as the national coordinator for health IT, he is proving to be more of an engineer.

For the last two years, Brailer has set in motion health IT efforts that individually and in tandem will let physicians, hospitals, insurers and pharmacists exchange patient data to transform the quality of medical care.

Like the gears of a complex machine, he said, the health IT efforts are beginning to mesh and are building a national momentum that promises to change the way physicians go about the business of providing health care and change the way Americans receive it.

'These are all different gears that have to turn together to get the wheel to turn. What's happening is that they're all turning and they're turning slightly out of speed with each other, but they're all starting to get cranked up,' Brailer said.

The initial efforts that the Health and Human Services Department is cranking up this year will give physicians and consumers their first dose of what is to come.One example would be retiring the medical clipboard holding those paper forms that patients fill out over and over, often with the same information, at their physician's office. Some consumers will be able to use an electronic registration summary containing information such as name, address and basic medication history, that they can direct their physicians to use.

As each critical cog of the health IT machine turns another notch this year, the success of each near-term result will help propel the realization of long-term health IT goals. Those include adoption of interoperable electronic health records by physicians and hospitals, easy-to-use personal health records that consumers own, remote monitoring systems for patients with chronic conditions, and electronic tools for real-time nationwide public health event monitoring and rapid response to crises.

HHS has seeded or promoted'or greased the wheels of'eight major initiatives that depend on physicians, hospitals, insurers, IT companies and government working together.

Over the long term, Brailer anticipates that the adoption of electronic health records and transformation of business processes in physicians' offices and hospitals will improve the quality of health care, reduce medical errors and cut costs.

'We're doing things that precipitate specific examples of change that can be real evidence of what's to come,' Brailer said.

Grabbing the low-hanging fruit first to show early successes is an example of how the federal government is taking the right initial steps to push health IT adoption, said Robert Cothren, chief scientist for Northrop Grumman Corp., one of the contractors for a nationwide health information network architecture.

'It's one thing to talk about these things. But if you can touch it and feel it, then you start to believe the stories,' he said.

Besides mothballing the medical clipboard, the public-private American Health Information Community, which HHS secretary Mike Leavitt leads, has made these early health IT uses its goal to become reality in 2007:

Transmit emergency room and physician office chief complaint data, such as fever or headache, in a standardized and anonymized format to public health agencies within 24 hours

Exchange secure messaging between physicians and patients so patients can begin to manage the care of their chronic conditions.

Initial standards are the foundation on which these early health IT versions depend. From May through August, AHIC will recommend what government and industry need to do to realize the short-term breakthroughs.

'We want to peel off the low-hanging fruit in May if we can to get started. We're facing real deadlines for getting some breakthroughs out,' Brailer said.

Major milestones

The Health IT Standards Panel plans to release in late August the first set of standards, which will support the portability of laboratory results as part of an electronic health record system. AHIC selected lab results for the panel to work on because widely accepted standards already exist, making them easy to agree on and simplifying the task of advancing a limited electronic health record capability.

'There's not this fractious debate that's been in other data areas,' Brailer said.Another key piece of the puzzle comes in June when the Certification Commission for Health IT will announce its first batch of vendors whose electronic health records systems meet its criteria for exchanging data. Certification will give physicians the assurance that the technology they invest in will perform as advertised.

These standards also will play an important role in the development of prototypes for a nationwide health information architecture. Four contractors are designing the draft architectures, scheduled to be completed by September, and HHS will put these architectures through several levels of review to, in part, make sure the information locator services, patient authentication, security protections and specialized network functions can work together. HHS also will test the feasibility of large-scale deployment.

By the end of the year, the four groups will each produce a prototype that reflects their individual approach. The prototype must be able to function but not necessarily be implemented and operational, said John Loonsk, director of the Office of Interoperability and Standards in the national coordinator's office.

'It is our expectation at the end of the year, after we've gone through a harmonization pro- cess, that we will have identified those standards that will enable the prototypes to be able to exchange data,' he said.

Playing it safe

Brailer's office also will start work on the biggest challenges: security and privacy. The Health Information Security and Privacy Collaboration will announce state subcontracts later this month in coordination with the National Governors' Association. The Health Insurance Portability and Accountability Act provides a baseline for health information privacy and security among states. But some states have established more stringent privacy laws, which could pose challenges for interoperability of electronic health record systems. HHS hopes that a partnership between states and federal leaders will evolve to develop models for privacy, and the subcontracts are the chief enabler of that, Brailer said.

One other key piece in the health IT puzzle is an exception to the Stark Law, governing physician self-referral of Med- icare and Medcaid patients, and anti-kickback laws to encourage investment in health IT. The exception, which HHS proposed last year, is about to be finalized, although Brailer said that, by law, he could not indicate when. Under the exemptions, hospitals could provide hardware, software and training to physicians who refer patients to them, which is currently illegal.

'It's a front-burner issue. The next public step we do is the final rule,' he said.

Equipment question

The anti-fraud laws currently are broad and limit the value of what a provider can give to physicians if they refer patients to the provider, said Peter Kazon, senior counsel at Alston and Baird LLP in Washington, and a former Federal Trade Commission attorney specializing in health care. A large hospital, lab or pharmacy benefits provider likely would want to integrate all physicians with whom they do business into their network.

'Is it necessary for a provider to be giving equipment? That's a $100,000 question,' Kazon said.

The federal government has a large stake in health IT, since it pays for almost 50 percent of health care costs through Medicare, Medicaid, federal employee health plans and military and veteran health benefits.

Just by getting the government involved, there's been an increase in interest in health IT, Northrop's Cothren said.

'In some respect, this has already been a wildly successful program, even though we're still in the early stages, because all that discussion is new and [government] is very active in moving forward,' he said.

HHS is trying to coordinate activities of all the major stakeholders across an entire industry around adoption of health information exchange and electronic medical records, said Greg DeBor, partner for global health solutions at Computer Sciences Corp., also an NHIN contractor.

'They need to keep in mind all those different groups' perspectives, to some extent attenuate them, so they can herd the cats that they need to make adoption happen in an accelerated time frame,' DeBor said.

Their progress has been good, and what they have done well is set up transparent and process-driven groups, such as the contract collaborations and AHIC.

Heavy lifting

That coordination effort is getting everyone on the same page and will spur agreement on terminology and standards.

'I can see the heavy lifting that wasn't being done in large scale across the industry,' DeBor said.

The government is helping to jump-start the health IT market as it has done historically with other industries by putting up seed money to develop new technologies, he said'as it did with the Internet, which grew out of Defense Advanced Research Projects Agency.

HHS' health IT efforts are a process of moving and coordinating parts.

'I wouldn't call it quite a clean-turning circle, but we did not want to set these up as separate, disparate pieces. All the pieces flow together with significant interdependencies,' Brailer said.

Ultimately, the adoption of interoperability standards and common terminologies will let scientists mine huge amounts of medical data to identify trends and best practices, said Dave Webster, certified executive IT architect at IBM Corp.'s Business Consulting Services.

'I am convinced that the next big medical breakthrough will occur once we make the use of standard, clinically-relevant codification schemes the rule rather than the exception,' he said.